Unprecedented population growth in developing countries will increase pressure on the environment and on the earth's carrying capacity. The current phenomenal growth in urbanization in developing countries has exacerbated efforts to secure environmental health. In India, the urban population is growing at a faster rate than the rural population, with about half of urban dwellers living in slums. Therefore, efforts to improve conditions in slums have been the subject of a number of recent projects. Challenges include providing sufficient housing in urban areas and improving ventilation, illumination, and exhaust of cooking fuels in rural houses. The water supply is threatened both in quality and quantity, and 89.2% of households in India lack or fail to use latrines. Lack of proper management of solid wastes and lack of drainage has led to serious health risks, and the safety of the supply of edible food sold in shops and schools is far from satisfactory. A lack of proper hygiene associated with infant feeding contributes significantly to infant mortality. School children exhibit a lack of personal hygiene, and often play in dirt and muddy water. Other problems are associated with the environmental ill-effects of home-based industries, pollution of the air and rivers, and behavioral-related health problems such as alcoholism, drug addiction, and high-risk sex behavior. Many innovative approaches exist as models for the development of the information, education, and communication programs necessary to improve the environment.
Globally, there have been improvements in the world's health, but in many countries the infant mortality rate is rising. Widespread disease is present in many developing countries. 250 million people suffer from filariasis and 30 million more have onchocerciasis or river blindness. 200 million are infected with schistosomiasis and each year 150 million new cases of malaria are registered. Over 5 million children die from diarrheal diseases in developing countries. Many health experts now believe that there is a way to rectify this situation by transforming the medical technostructure. The challenge for the "Health for All" movement is to find a health service that people can afford and in which people can play a major role. Community participation is an important part of this movement. Lower costs for health care, better distribution of funds for health, and more equitable distribution of resources are necessary. The concept of "Health for All" challenges the prevailing concept of development in which human communities are considered passive.
Throughout the world, the concept that the best milk is breast milk is gaining momentum from ever increasing supportive scientific evidence. In India the average mother even with her poor nutritional status has the ability to breastfeed her infant for prolonged periods, sometimes extending to nearly 2 years. Human milk generally forms the only source of dietary protein for poor Indian infants, and the nutritional status of poor infants and children would be much worse than what it is today if not for breast milk. The positive economic and health implications of breast milk are obvious; it is the most hygienic, safest, and suitable nourishment a mother can provide for her infant. Recently, there has been an unfortunate trend toward artificial feeding among the average Indian mother. This practice is spreading among rural mothers and mothers of low socioeconomic groups. Due to poverty and ignorance many mothers neither can prepare the artificial milk feeding formula hygienically nor feed their children well, and the children are not only deprived of essential nutrients but are exposed to unnecessary intestinal infections introduced through unsterilized bottles and nipples. The Protein Advisory Group of the UN has warned against early abandonment of breastfeeding, particularly in poor families, as devastating to the health and survival of infants. The practice of artificial feeding also has adverse economic implications. The expenditure incurred in the processing, packing, distributing, preparing, and refrigerating cow's milk is enormous and one that a developing country like India cannot afford. Breast feeding also has the advantage of a certain amount of contraceptive effect. Generalizations for the promotion of breastfeeding include the following: 1) unsupplemented human milk is all that is needed to sustain growth and good nutrition for the first 6 months of life; 2) the volume and composition of human milk among poor women is surprisingly good despite their low nutrition status; and 3) limited studies have suggested that improvement in both the quantity and quality of breast milk is feasible. Modifications that should be made in health services are outlined.
Sri Lanka's population activities at the national level are undertaken through 12 multidisciplinary programs involving several UN agencies and 7 national ministries. The projects cover major areas of the program and are funded by the United Nations Fund for Population Activities (UNFPA). They do not function in isolation and are components of the family health program. Sri Lanka possesses an impressive infrastructure for population information and education and the main channels utilized are the mass media and interpersonal communication. A large army of field workers help in the effort to bring the message into the homes of the people. Population communication programs in Sri Lanka have demonstrated their effectiveness in disseminating, on a broad basis, factual information on population and family planning services and facilities. Communication activities also help to speed up the process of change, to reinforce knowledge, and to ensure a continuous educational system for the community in general and specific technical and basic information for target audiences in order to increase efficiency. Thus, population communication functions at 2 levels: that of providing basic information for purposes of motivation; and assisting in the decision making process. The mass media are used for the 1st purpose, and interpersonal efforts play a dominant role in the 2nd. Both these efforts, which are reviewed, are supported by other means of communication such as audiovisual aids, while multimedia efforts have been found useful in sustaining levels of interest in the program.
1.5 million children under the age of 5 years die of diarrheal disease every year. The incidence of diarrhea is highest among children 3-36 months of age with peak incidence between 6-9 months. Causes of diarrheal disease are poor sanitary facilities, poverty and ignorance leading to malnutrition, overcrowding, and unhygenic living conditions. Significant advances in knowledge have contributed to better treatment and control of diarrheal disease: the use of new viral and bacterial agents have aided in identifying the causative agents in 70% of diarrheal cases. Breastfeeding protects infants from the diseases. Water supply and sanitary conditions help to prevent diarrhea; however, these alone do not sufficiently control acute diarrheal disease. The primary cause of mortality from diarrheal disease is dehydration. In cholera, fluid losses can reduce body weight by 10% in 4-6 hours. Oral rehydration solution (ORS) has recently simplified the procedure of rehydration. Evidence indicates that the use of ORS at the household level can decrease the mortality to below 1%. Effective implementation of ORS at the community level depends on: 1) production of adequate quality of packets of ORS, 2) extensive training of health personnel, 3) education of mothers in the treatment of ORS, and 4) easy availability of ORS packets. In India, the Ministry of Health is giving high priority to large scale production of low priced ORS packets. In addition, training courses for medical and paramedical workers are being organized throughout the country. Control of diarrheal disease involves the implementation of improvements in water supply, sanitation, health education, and personal hygiene.
In discussing the lessons learned from research in the area of health communication, focus is on basic strategic issues; the scope of health communications in terms of audience, information, education and motivation approaces and India's satellite Instructional Television Experiment (SITE). Health communication is the process by which a health idea is transferred from a source, such as a primary health center, to a receiver, community, with the intention of changing the community's behavior. This involves the formulation of specific strategies for the conduct of health and family welfare communication. In the processs of health communication, it has been a common practice in India as well as in other developing countries to depend upon a plethora of communication media. Yet, despite maximum utilization of the mass media and interpersonal channels of communication, questions remain about the efficacy of the system in bringing about change. Thus, the need to draw upon lessons from research becomes obvious. Communication effectiveness researches have concentrated on 3 basic strategic issues: the question of physical reception of messages by the audience; interpretation or understanding of messages on the part of the audience in accordance with the intention of the communicator; and effectiveness of communication on the cognitive, affective and behavioral dimensions of the audience. Innumberable researches in communication have provided several lessons which have expanded the scope of health communication. This expansion can be observed in terms of audiences reached, information disseminated, education undertaken, and motivation provided. Research has identified several distinct groups to whom specific health messages have to be addressed. These include government and political elites, health and family welfare program administrators, and the medical profession and clinical staff. Information on health needs to include both the concept of health and the pertinent ideas and facts about various health measures and available services. The innovative approach is more functional, and it tries to consider the values and attitudes of the audience that it hopes to reach. The health programs on SITE have been very well received by the rural audience in India according to several studies conducted by the various agencies.
The following were among the questions directed to India's Prime Minister Indira Ghandi: what priorities does the government accord to the family planning program; is there any alternative for economic viability for the country in the face of failure to curb the population growth rate to a manageable proportion; should family planning be part of the minimum national consensus, i.e., above party politics; what steps is the government taking to revitalize the family planning program; and is there a need to review the law in order to determine how it can be made more supportive of the family planning effort. Ghandi noted that India's government was the 1st in the entire world to adopt family planning as a official program, and this action shows how important family planning is to the country. She maintained that the real answer is development--development to provide what the people really need and development because it helps to curb families. Ghandi made the point that a subject like family planning should be above any controversy, but in actuality there has been considerable propaganda against family planning in India. To revitalize the program, Ghandi identified the need for involving the entire population rather than just the department in charge of family planning. She indicated that schools, the youth movement, women's organizations and other institutions which are concerned with any type of social welfare should be involved in family planning. Finally, Ghandi reported that the government is doing a great deal to raise the status of women in India, beginning by helping girls to continue their education.
In an effort to ensure the mental and physical well-being of mothers and children in Tamil Nadu, India, Maternity and Child Welfare Services have been included as 1 of the major programs envisaged in the health care delivery system. The objectives of the Maternity and Child Welfare Services (MCW) is to provide free and skilled assistance, health care and health education to all pregnant mothers during pregnancy, delivery, and the postnatal period. The Director of Public Health and Preventive Medicine is in charge of the program. During 1955-1956, under the "Backward Area Scheme," 19 main MCW centers with 4 subcenters attached to each main center were opened. For those rural areas that did not come under the Backward Area Scheme, the MCW services were provided through the MCW Centers operated by Panchayat Unions. The Maternal and Child Health Services (MCH) in municipal areas are provided through maternity centers and homes established and maintained by Municipal Councils in accordance with the norms established by the government. There are 430 Municipal Maternity Homes and MCW centers in the State. The MCH services in the State include antenatal, natal and postnatal care along with infant care, of preschool children and school health in addition to family welfare. Children get immunized in the MCW centers, in the school and in their homes. The number of children examined under the Special School Health Program during 1977-1978 was 129,516, 88% of the target. 2 kinds of health visitors training is being provided at this time.
Tamil Nadu is the first Indian State to recognize the basic relevance of family planning to national planning. It was given national awards for outstanding work in family planning for every year except 1964 from 1961 to 1967, and from 1973 to 1976. Family planning activity was initiated in large maternity hospitals as a postpartum program. The Medical Termination of Pregnancy Act was first implemented in Tamil Nadu. 141 institutions have been certified for the operation. An oral pill program is being implemented in all the rural and urban family welfare centers including the hospitals. The family welfare program has been fully integrated with the Maternal and Child Health (MCH) program which has created confidence among people that their children will be protected from health hazards. The MCH Schemes are conducted through primary health care (PHC) centers, urban family welfare centers, MCH centers, hospitals, and dispensaries. Dais are trained to improve the techniques of midwifery and aid delivery in a hygienic manner. Dais can also use their influence in the local community to further family planning. It is proposed to establish additional subcenters in selected districts to average 1/center/5000 population. The government continues to sponsor and fund equipment, facilities, and infrastructure to facilitate sterilization operations in primary health centers.
The incidence of smoking has increased significantly in the past several decades. Studies have been conducted in many Western countries into the effects of cigarette smoking on health. The following conclusions of the U.S. Public Health Services study are cited: 1) cigarette smoking is causally related to lung cancer in men; 2) the risk of developing lung cancer is related to the amount and duration of smoking; 3) pipe smoking is causally linked to the development of lip cancer; 4) cigarette smoking is the most important cause of chronic bronchitis in the U.S. and 5) cigarette smoking is related to the incidence of pulmonary emphysema, acute cardiovascular effects, and peptic ulcer. Several studies on smoking which have been conducted recently in India are also cited. Epidemiological data collected from all parts of India over a 10-year period have shown an increasing trend in the incidence of lung cancer. This and the high incidence of chronic bronchitis are attributed to the increase in smoking in the country. The government has required a warning to be placed on every cigarette pack. More restrictive measures against cigarette smoking are recommended. Education of the public to the hazards of smoking is necessary.
Inaugurating the Joint Conference of the Central Council of Health and Central Family Welfare Council on April 27, 1979, in New Delhi, the Prime Minister of India, Shiri Morarji Desai, advised personnel of family planning programs never to use coercive methods. He suggested that persuasion would better educate people on the need for small families, and that, if proper methods were employed, the message of family planniang would reach every family within 4-5 years. Desai also said that although the modern system of medicine was the best, and had the primary place in the country, other systems, such as Naturopathy, should not be neglected in treating people who believe in it.
In 1972 the government of India appointed a committee to study the extent of the problem of the untrained dais and to review the training program for this group. This exploratory study aims at determining factors responsible for poor response to the dais' training program and the community's attitude towards the trained dais. 3 villages with a health sub-center and an ordinary village were selected for the rural area. Dariba Kalan was the selected urban area. An exhaustive list of live births during 1972 along with the name of the birth attendant in each case was compiled from health center records for these areas. Of the 278 births in the 3 villages, 55% were conducted by the untrained dais and the remaining 45% by the center staff. In the urban area 108 births were reported of which 79% were cared for by center staff and 21% by traditional trained dais. No untrained traditional dai was located in the study urban area. A suggestive assessment of quality of ante-natal, natal and post natal services provided by different categories of dais suggests that an indigenous trained or a maternal and child health center dai provides better services than an untrained dai. 37% of the mothers who did not call center dai for help with their deliveries in the rural area felt that the center staff would not be easily available at the time of delivery; 23% gave their reason for not calling the staff as lack of faith. These findings suggest that the community needs to be made aware of the training program and its benefits and a systematic educational plan is required for this purpose.
Considerable effort has been made in the area of family planning in the State of Punjab. Family planning personnel has been recruited and trained at the State Family Planning Training and Research Center in Kharar; supplies of Nirodh, IUDs, oral contraceptives, and hospital equipment along with transportation facilities have been made available; and there has been some building construction. The State Health Education Bureau has worked to produce publicity material and has also used the mass media to create awareness of family planning among the people. As many as 120 rural and 49 urban Family Welfare Planning Centers are providing family planning services along with 856 subcenters in rural areas. 1123 other institutions are also doing family planning work in addition to the efforts of 34 mobile sterilization and IUD units attached to the District Family Planning Bureau and the contributions of some voluntary organizations. Although the state has adopted the cafeteria approach to family planning and the focus is on provision of family planning services on routine days in the various institutions to well-motivated couples, mass family planning camps for vasectomy, tubal ligations, and IUD insertions have been held with considerable success. Additionally, the State has integrated family planning programs with maternal and child health care in order to provide a totality of service. This precedes the total integration of this national program w ith general health services. Punjab has done well in achieving its targets for 1974-1975. Sterilization targets were set at 38,300 and 36,460 sterilizations, 95.2% of the target, were performed. IUD targets were 27,000, and the number achieved was 39,637 or 109.4%. The conventional contraceptive user target was 99,800, and 151,976 or 152.3% of the target figure became conventional contraceptive users.
Western nations tend to exaggerate the role of countries like India in the world's population crisis and tend to blame resulting threats on their life styles on having to support the populations of developing countries when in fact a tiny minority in the affluent countries uses up food and energy resources out of all proportion to their needs. The birthrate in India should be brought down, but should be because of the conviction of Indians that family planning is essential for improving the national standard of living. The most progress in family planning has been made in states with a well-developed social infrastructure. Care needs to be taken that the program is maintained for all people and not just for family planning circles, and that the movement does not become a victim of rules. It should push ahead in areas of high promise, such as the industrial growth points. Special attention should also be given to the most backward areas, and an effort should be made to shift the primary responsibility for family planning from women to couples. More imaginative methods have to be devised to convince couples to adopt.
2 broad points of view toward determining the nature of India's investment to affect a demographic transition and thus avoid further losses of social welfare are weighed: 1) all investment efforts should be directed towards lowering the fertility ratio as much as possible, and 2) a fixed capital formation in directly productive activities should be maintained without adopting a deliberate population policy.
Family planning must be combined with economic and social progress to bring about improvement in the development of the country. Fertility measures in India have shown a decline from the 1961 level. During the years 1961-1970, the age at marriage has increased from 13 to 18.3 for women and from 20 to 23.8 for men. The decline in fertility rates may be due to the increased age at marriage and use of family planning by younger couples. Awareness of the population problem and family planning, and attitudes, knowledge, practice, and preference differ greatly at the local levels. There is a pressing need for research in the social and cultural aspects of family planning. Greater opportunities for the young and women in socioeconomic areas will tend to increase participation in decisions which will moderate fertility.
There is little difference in height at birth between Indian and Wes tern babies; weights at birth and subsequent growth patterns are lower for the Indian babies. In India boys traditionally receive better treatment with regard to diet medical aid and education. This leads to nutritional deficiencies among Indian women higher maternal diseases and lower female life expectancies. Due to under- and malnutrition during preadolescent growth the adolescent growth spurt and age at menarche among Indian girls is delayed. Particular attention should be given to improving the health and nutrition of adolescent girls in order to prevent infant and maternal mortality and to improve maternal and child health in India.
Family planning in Andhra Pradesh has gained momentum and has experienced considerable gains with nearly 1.5 million couples protected through sterilization and IUD insertions since the inception of the program. 2,6000,000 births are estimated to have been avoided since 1966. Estimated population in 1974 was 46,383,000 with a growth rate of 20.90%, well below the India average of 24.80%. More and more emphasis is now being laid on people's participation, integration with maternal and child health, immunization programs, nutrition, health education, and other welfare measures, and to this end 4 multipurpose workers' schemes are being introduced in East Godavari, Chittoor, Nellore, and Nalgonda. In order to involve the community at large in measures for improvement of health and family planning, village health centers are being formed. They are proving to be popular. There has been a marked decline in the proportion of deliveries in the higher parities among total deliveries in major hospitals of the State. About 2000 abortions are performed annually. There is a growing demand for abortion facilities throughout the states and abortion laws may be liberalized. In the recent past there has been increasing evidence of the feasibility of adopting a simpler method than abortion to terminate and unwanted pregnancy, menstrual regulation. It is felt that both menstrual regulation and abortion will be readily accepted.
The requirements for an adequate system of maternal and child health care are outlined, including, instruction in health and sex education before marriage, preferably beginning early in school; adequate prenatal care (i.e., monthly examinations until the 28th week, biweekly checkups from the 28th to the 36th week, then weekly thereafter) which should include instruction in diet and a complete physical examination; delivery services and postpartum checkups; infant care instruction, including feeding instructions; and infant immunization and health monitoring services. In India, maternal and child health care services are provided through a network of primary health centers and subcenters in rural areas. The maternal-child health care personnel regularly visit homes. In urban areas there are public and private hospitals and maternity homes. The maternal-child health services, both rural and urban provided by each state in India are listed in chart form.
